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LONG-TERM CONDITIONS 548 British Journal of Community Nursing November 2016 Vol 21, No 11 Integrating nutrition into pathways for patients with COPD Matthew Hodson Chair, Association of Respiratory Nurse Specialists; Honorary Respiratory Nurse Consultant, Homerton University Hospital, London [email protected] M alnutrition is an imbalance of energy, protein and other nutrients that cause adverse effects on the body (size, shape and composition), the way in which it functions and clinical outcomes (Elia, 2000).

The term can refer to under-nutrition (being under-weight or losing weight) or over-nutrition (being overweight or obese), for the purposes of this article we are focusing on the issue of under-nutrition in COPD.

According to the British Lung Foundation (BLF) approxi - mately 1.2 million people in the UK are diagnosed with COPD (BLF, 2012), it is estimated however that more than 3 million people may live with the disease (NHS Choices, 2014). Around 21% of outpatients with COPD (up to 630,000 people in the UK) are at risk of malnutri - tion (Collins et al, 2010). Malnutrition may develop follow - ing periods of exacerbations or gradually over several years. Community nurses play a vital role in the ongoing care of patients living with COPD, and are ideally placed to identify patients who are at risk of malnutrition and implement an appropriate nutritional care plan.

Causes of malnutrition The causes of malnutrition in patients with COPD are var - ied, some of which are detailed in Table 1 . The consequences of malnutrition The consequences of malnutrition in COPD patients are significant and varied and are likely to further affect nutri - tional intake (Cochrane and Afolabi, 2004). Evidence sug - gests that patients with COPD at risk of malnutrition have an increased risk of hospitalisation, longer hospital stays, more frequent readmissions and increased mortality (Steer et al, 2010; Weekes et al, 2007). In patients with a low BMI (<20kg/m 2) 1-year mortality is four-fold higher when compared to overweight or obese patients (BMI >25kg/ m2) (Collins et al, 2010). The cost of malnutrition As outlined the clinical consequences of malnutrition in patients with COPD are widespread. These undoubtedly have financial implications. Current evidence estimates that the total cost of malnutrition in England alone is £19.6 bil - lion (Elia, 2015). This research also estimates that the health and social care costs of patients at risk of malnutrition is over 3 times that of non-malnourished patients (£7408 versus £2155) (Elia, 2015). Treating the 1 in 5 patients with COPD who are estimated to be at risk of malnutrition could there - fore relate to significant cost savings to the health and social care system. When a budget impact analysis is applied it can be shown that the investment necessary to implement better nutritional care is more than counteracted by the result - ing cost savings, and when the Clinical Guidelines (CG32)/ Quality Standard (QS24) is applied to 85% of patients with a high risk of malnutrition it has been suggested that there ABSTR ACT This article looks at the role of the community nurse in assessing the nutritional status of patients with COPD and in integrating nutrition in\ to the COPD care pathway.

KEY WORDS w COPD w malnutrition w low BMI w nutritional screening w oral nutritional supplements Table 1. Causes of malnutrition in COPD Disease effectsPatients with COPD have increased nutritional requirements due to a high energy expenditure caused by systematic inflammation and increased requirements during breathing (Ezzell et al, 2000) Medication effects The use of oxygen, nebulisers and inhalers can cause dry mouth making it difficult for patients to swallow foods and this can also lead to taste changes (Manual of Dietetic Practice, 2014) Psychological factors The disease may cause patients to suffer from lack of motivation, anxiety and depression Social factors Patients may suffer from social isolation (Odencrants, 2005) Environmental factors Patient’s living conditions may not be ideal to assist with food preparation 2016 MA Healthcare Ltd LONG-TERM CONDITIONS 550 British Journal of Community Nursing November 2016 Vol 21, No 11 would be an overall cost saving of approximately £120 000 per 100 000 capita (Elia, 2015).

Nutritional screening NICE recommends that BMI is calculated in all patients with COPD (NICE, 2010) using a validated screening tool (e.g.‘MUST’). Screening should take place on first contact with the patient and/or upon clinical concern (for example after an exacerbation or a change in social or psychological status). A review should take place at least annually or more frequently if risk of malnutrition is identified (NICE, 2006).

‘Managing Malnutrition in COPD ’ is a new practical guide that has been launched to assist health professionals, and particularly those working in the community, in identify - ing and managing people with COPD who are at risk of disease-related malnutrition and includes a pathway for the appropriate use of oral nutritional supplements. The docu - ment and supporting patient materials have been endorsed by 10 key professional and patient associations including the Association of Respiratory Nurse Specialists (ARNS), the British Dietetic Association (BDA), the British Lung Foundation, the Royal College of Nursing (RCN) and more recently received an endorsement statement from the National Institute for Health and Care Excellence (NICE) (see Box 1 ). This new guidance, which replaces the ‘ Respiratory Healthcare Professional’s Nutritional Guideline for COPD Patients ’ launched in 2011, provides an up to date consensus of evidence and expert opinion in identifying and manag - ing patients with COPD who are at risk of malnutrition.

It includes an easy to follow flowchart that logically guides the user through the ‘Malnutrition Universal Screening Tool’ (‘MUST’); a 5-step approach to assessing and manag - ing those who may be malnourished or at risk of malnutri - tion. Steps 1–3 calculate BMI, weight loss and acute disease affecting the patient’s ability to eat for 5 days or more (the latter being less likely in the community). Step 4 combines the scores from steps 1 to 3 and formulates an overall score of between 0–6, which is then utilised in step 5 to identify the level of malnutrition risk to the patient and the appropriate intervention required.

Where it is difficult to ascertain the patients weight, alter - native measures such as a mid-upper arm circumference (MUAC) measurement and subjective (visual) assessment of the patient can be used to help formulate a clinical impres - sion of the patient’s risk category. Further information on MUAC and alternative measurements can be found via the ‘MUST’ Report – www.bapen.org.uk/pdfs/must/must_explan. pdf. The ‘ Managing Malnutrition in COPD ’ pathway outlines the nutritional intervention required, advising when to refer on to a dietitian and also when a prescription of oral nutri - tional supplements may be required; a pathway for using oral nutritional supplements is also included, which advises when and if oral nutritional supplements are appropriate, monitor - ing of compliance and progress, and advice on when to stop the prescription of oral nutritional supplements.

Assessing patient needs and goal setting As already outlined it is important that we carry out a nutri - tional assessment of our patients so that we can understand the physiological, social, psychological and environmental factors that may affect the patients ability to eat and can help to restore some pleasure for the patient around food, help - ing to meet their nutritional needs and own personal goals.

Discussions around diet and lifestyle can assist in producing a tailored nutritional care plan and in agreeing the most appropriate goals for the patient.

It is important to set realistic patient goals that are achiev - able for the individual. The setting of such goals should be made in partnership between the patient and the health pro - fessional, ensuring a patient-centered approach to nutritional care. It should be noted that where patients are malnourished a 2kg weight increase is a suggested threshold where func - tional improvements are seen (Collins et al, 2013; Collins et al, 2012; Stratton and Elia, 2007; Schols et al, 1998), however, timescales for such a weight increase will depend on the patients overall condition and simple goals aimed at increas - ing calorie and protein intake may be the most effective.

Stopping smoking may also help with improving the senses of taste and smell making food more pleasurable, so smoking cessation is also a key thread throughout consultations with Box 1. NICE Endorsement Statement – Managing Malnutrition in COPD National Institute for Health and Care Excellence August 2016 This guide supports some of the recommendations on identification and \ management of malnutrition in the NICE guideline on nutrition support in adults and chronic obstructive pulmonary disease in over 16s. It also\ supports the statements about identifying and managing malnutrition in t\ he NICE quality standard for nutrition support in adults.

This resource is intended for use with adults and not children.

2016 MA Healthcare Ltd LONG-TERM CONDITIONS British Journal of Community Nursing November 2016 Vol 21, No 11 551 Box 2. Tips for high risk patients (The following information is available in a patient leaflet - ‘Nu\ trition Support in COPD’ (red leaflet) which is available free to download from www.malnutritionpathway.co.uk/copd ) Making the most of food and drink The following advice aims to help patients with COPD make the most of th\ eir food and drink; it should be noted that some of this advice is contrary to the healthy eating advice that patients may have previously \ followed and they may be concerned about weight gain. It is important that the goals of these nutritional interventions (e.g. to improve or p\ reserve lean body mass, overcome infection, improve ability to perform daily activities etc.) are discussed with the patient. Not all advice m\ ay be acceptable to all patients so talking through the possibilities and picking out those which they feel are achievable goals can be helpful:

wwChoose full fat or high energy options e.g. whole milk, and avoid low fa\ t or ‘diet’ varieties. Include them in your diet as often as possible as part of meals or snacks:wwHigh energy foods are those that are high in fat (e.g. chips, fried foo\ ds, meat pies), high in sugar (e.g. fizzy drinks, sweets), or high in both sugar and fat (e.g. chocolate, cream cakes)wwAdd grated or cream cheese to mashed potato, soups, sauces, scrambled eg\ gs, baked beanswwAdd cream to sauces, scrambled eggs, soups, curries, mashed potatoes, de\ sserts and porridgewwUse mayonnaise, salad cream or dressing in sandwiches and on saladswwAdd extra butter, margarine or ghee to vegetables, potatoes, scrambled eggs and breadwwFortify your usual milk: whisk 2–4 tablespoons of milk powder into on\ e pint of milk, use for drinks, on cereals etc.wwAdd honey, syrup and jams to porridge, milky puddings, on bread, toast or tea cak\ eswwTake nourishing drinks e.g. smoothies, soups, fruit juice, milkshakes or \ hot chocolatewwUse convenience foods from the cupboard or freezer, e.g. long life milk, savoury snacks, biscuits, rice puddings, corned b\ eef, baked beans, soups, tinned puddings and custardwwDon’t fill up on drinks before or during mealswwEat more of the foods that you enjoy at the times of day when you feel m\ ore like eating If patients who are living independently feel too tired to shop for, prepare or cook meals the following could be considered:

wwAsking a family member, friend or their carer to help with cooking, shopping or ordering food \ for home deliverywwDo they need to be assessed for a package of care (via social services)\ ?wwCould you recommend a local ‘meals on wheels’ service or home deli\ very services offering pre-prepared meals?wwCould they arrange to eat regularly with a friend or family member or at\ tend a local lunch club?

Oral nutritional supplements (ONS) If patients are struggling to eat enough to meet their nutritional needs\ they may be prescribed oral nutritional supplements (ONS) – it is recommended that patients with COPD and a low body mass index (BMI <20k\ g/m 2) are prescribed ONS (NICE CG101, 2010). ONS provide extra energy, protein, vitamins and minerals and are usually taken in addition to th\ e normal diet, and unless advised they should not replace food, drinks or meals.

There are a range of styles, types, formats and flavours available (e\ .g. ready-made drinks, powders to be made up with fresh milk, savoury, dessert, milk, juice or yogurt styles).

Some ONS contain more of certain nutrients (e.g. extra protein and/or e\ nergy), which may be helpful for some people with COPD, some are also available in a smaller volume, which may be easier to manage if a patien\ t is breathless or struggles to eat or drink large amounts.

If patients are prescribed ONS they should be monitored by a health prof\ essional to ensure compliance – this should initially take place after 6 weeks, then after 12 weeks and then every 3 months, or sooner if there\ is clinical concern. Once nutritional goals have been met the ONS prescription can be stopped (Managing Malnutrition in COPD, 2016). The\ ‘Managing Malnutrition in COPD’ pathway for using ONS gives further details of this intervention.

A leaflet for health professionals containing more information on ONS \ along with an up to date list of available products is available from: www.malnutritionpathway.co.uk/files/uploads/Managing_Malnutrition_with_ONS_final_2016.pdf Pratical dietary advice/tips for common symptoms COPD patients may have a number of issues when eating and drinking and t\ here are several practical tips that nurses can give to patients: Patients who are short of breath may struggle to eat large amounts, tips\ to assist them include:

wwChoose softer, moist foods at these times, e.g. casseroles, curries, adding sauces, g\ ravy, milky puddings, fruit smoothies, ice creamswwAim to eat something 6 times per day, even if it is smaller meals and nutritious drinks or snacks between Dry mouth can be caused by using oxygen, nebulisers or inhalers and can \ make it difficult to chew and/or swallow foods. Tips to help include:

wwChoosing softer or moist foods, e.g. minced beef in shepherd’s pie rather than pieces of dry meatwwSucking fruit sweets, ice cubes made with fruit juice or squash, or chew\ ing sugar-free gumwwPastilles or saliva sprays can be prescribed if the problem continues Changes in taste (another consequence of dry mouth) which may cause lo\ ss of appetite and put the patient off their usual foods. Helpful hints include:

wwAfter using a steroid inhaler rinse your mouth and gargle with water to \ prevent oral thrushwwLook after your mouth: regularly clean teeth/dentures, use mouthwash and\ flosswwFocus on the foods you enjoy but don’t be afraid to try new foodswwTry sharp or spicy or sugary foods, as they have a stronger tastewwExperiment with different seasonings and sauceswwIf you go off a particular food try it again regularly as your tastes ma\ y continue to change 2016 MA Healthcare Ltd LONG-TERM CONDITIONS 552 British Journal of Community Nursing November 2016 Vol 21, No 11 patients. Pulmonary rehabilitation is a recommended part of the management of patients with COPD. Malnourished patients undertaking such exercise programmes will have increased energy requirements and nutrition interven - tion is likely to support the effectiveness of such exercise programmes in malnourished patients (Schols et al, 2014; Collins et al, 2013; NICE, 2010; Sugawara et al, 2010; Van Wetering et al, 2010). Additional assistance and advice may be needed during periods of exacerbation when nutritional requirements are likely to increase and nutritional intake may decrease.

Community nurses are ideally placed to discuss and assess the many issues outlined that may affect a patient’s ability to eat and drink, and to refer patients to relevant professionals, such as a dietitian, specialist respiratory nurse/physiotherapist or social care professional, who can assist them further with other concerns if required.

As part of the newly launched ‘ Managing Malnutrition in COPD ’ guidelines three colour coded patient leaflets have been developed to complement the pathway – the red leaflet is for those patients who have been identified at high risk of malnutrition, yellow for those at medium risk and green for those at low risk. The leaflets include simple tips for making the most of food and drink in order to improve nutritional intake as well as advice on the use of oral nutritional supple - ments when required. They also provide advice for coping with common symptoms such as shortness of breath, dry mouth and taste changes. All can be downloaded for free via the website – www.malnutritionpathway.co.uk/copd. The information in Box 2 , taken from the ‘ Managing Malnutrition in COPD ’ materials, aims to assist community nurses in their discussions with patients about their diet and issues with eating.

Conclusions Malnutrition is common among COPD patients and com - munity nurses play an important role in the nutritional assessment of these patients. The ‘ Managing Malnutrition in COPD ’ guideline has been developed to assist community health professionals in identifying and managing malnutri - tion appropriately and the pathway is supported by patient materials aimed to advise patients on their nutritional intake. It is hoped that these materials will be integrated into existing COPD care pathways to ensure that patients are screened for malnutrition and receive appropriate nutritional care. Copies of the ‘ Managing Malnutrition in COPD ’ docu - ment and supporting patient materials are available free to download via www.malnutritionpathway.co.uk/copd. BJCN Accepted for publication: October 2016 Declaration of interest: None British Lung Foundation (2012) Chronic obstructive pulmonary disease (COPD) statistics. www.statistics.blf.org.uk/copd (accessed 7 September 2016) Brotherton et al (2010) Malnutrition Matters Meeting Quality Standards in Nutritional Care. A Toolkit for Commissioners and Providers in England. www. bapen.org.uk/pdfs/bapen_pubs/mm-toolkit-exec-summary.pdf (accessed 12 October 2016)Cochrane WJ, Afolabi OA (2004) Investigation into the nutritional status, dietary intake and smoking habits of patients with chronic obstructive pulmonary disease. J Human Nutr Dietetic s 17: 3–11 Collins PF et al (2013) Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Respirology 18: 616–29 Collins PF et al (2012) Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta- analysis. 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Commission for Healthcare Audit and Inspection: LondonManaging Malnutrition in COPD: Including a pathway for the appropriate use of ONS to support community healthcare professionals. 2016. www.malnutritionpath - way.co.uk/copd (accessed 12 October 2016) Gandy J (2014) Manual of Dietetic Practice . Blackwell Publishing: London National Institute for Health and Clinical Excellence (2010). NICE clinical guide - line CG101. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. National Institute of Health and Clinical Excellence (2006). NICE clinical guideline 32. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. www.nice.org.uk/guidance/CG32 (accessed 20 October 2016) NHS Choices (2014) Chronic obstructive pulmonary disease. www.nhs.uk/ Conditions/chronic- obstructive-pulmonary-disease/Pages/Introduction.aspx (accessed 12 October 2016)Odencrants S et al (2005) Living with chronic obstructive pulmonary disease: Part I. Struggling with meal-related situations: experiences among persons with COPD. Scan J Caring Sci 19: 230–9 Schols AM et al (2014) Nutritional assessment and therapy in COPD: a European Respiratory Society statement. Eur Respir J 44: 1504–20 Schols AM et al (1998) Weight loss is a reversible factor in the prognosis of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 157 : 1791–7 Steer et al (2010) Comparison of indices of nutritional status in prediction of in-hospital mortality and early readmission of patients with acute exacerbations of COPD. Thorax 65: A127 Stratton RJ, Elia M (2007) A review of reviews: A new look at the evidence for oral nutritional supplements in clinical practice. Clin Nutr 2(1): 5–23 Sugawara K et al (2010) Effects of nutritional supplementation combined with low-intensity exercise in malnourished patients with COPD. Resp Med 104 (12): 1883–9Van Wetering CR et al (2010) Efficacy and costs of nutritional rehabilitation in muscle-wasted patients with chronic obstructive pulmonary disease in a com - munity-based setting: a prespecified subgroup analysis of the INTERCOM trial. J Am Med Dir Assoc 11(3):179–87 Weekes et al (2007) A nutrition screening tool based on the BAPEN four ques - tions reliably predicts hospitalisation and mortality in respiratory outpatients. Proceedings of the Nutrition Society 66: 9 A KEY POINTS wwMalnutrition is prevalent among patients with COPD and has serious consequences for both the patient and local health care economy wwMalnutrition in COPD is often due to the effects of the disease but environmental, social and psychological factors also play a role wwPatients with COPD have a wide range of nutritional problems and should \ receive nutritional assessment, appropriate early nutritional interventi\ on and monitoring to improve patient experience and quality of life wwCommunity nurses are ideally placed to identify and manage patients living with COPD who are at risk of malnutrition, including referral to \ a dietitian for patients with complex nutritional needs 2016 MA Healthcare Ltd Copyright ofBritish Journal ofCommunity Nursingisthe property ofMark Allen Publishing Ltd and itscontent maynotbecopied oremailed tomultiple sitesorposted toalistserv without thecopyright holder'sexpresswrittenpermission. 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